Effect Of Malnutrition And The Benefits Of Investing In Child Nutrition

By Adewole Kehinde

I will be looking at both Nutrition and malnutrition across Nigeria but with particular focus on the North East zone due to the various intervention programs that has been introduced especially by UNICEF and Community Management of Acute Malnutrition (CMAM) in particular.

Experts agree that nutrition has a significant impact on child health, growth, and development in the first two years of a child’s life.

It is on records that scholars have discussed the effect of a nutrition intervention during early childhood on human capital (personal attributes such as knowledge, skills, health, and values, that increase individual productivity) formation and on the economic productivity of Nigerian adults.

Malnourished children require more health services and more expensive types of care than other children. Malnourished children have poorer schooling outcomes and may repeat years more often, thus increasing education costs. Developing countries are also spending an average of 2 to 7 percent of their health care budgets on direct costs for treatment of obesity and associated chronic diseases - and the obesity problem is rapidly worsening. All of these costs fall largely on governments, which provide extensive public sector financing for health and education for the poor. Returns from programs for improving nutrition far outweigh their costs Taking into account the reduced mortality, reduced medical costs, intergenerational benefits (reduced likelihood of giving birth to a low-birth-weight infant in the next generation), and increased productivity.

Nutrition and income poverty Under-nutrition and micronutrient malnutrition are themselves direct indicators of poverty, in the broader definition of the term that includes human development. But under-nutrition is also strongly linked to income poverty, although by no means synonymous with it. The prevalence of malnutrition is often two or three times—and sometimes many times—higher among the poorest income quintile than among the highest quintile.

This means that improving nutrition is pro-poor and increases the income-earning potential of the poor. In countries where girls’ nutrition lags behind, improving the nutrition of young girls adds an extra equity-enhancing dimension to any such investment. Poverty and malnutrition reinforce each other through a vicious cycle. Poverty is associated with poor diets, unhealthy environments, physically demanding labor, and high fertility, which increase malnutrition.

Malnutrition in turn reduces health, education, and immediate and future income, thus perpetuating poverty. Even worse, poor malnourished women are likely to give birth to low-birth-weight babies, thus perpetuating poverty in the subsequent generation. Addressing malnutrition helps break this vicious cycle and stop the intergenerational transmission of poverty and malnutrition.

Direct investment in health and nutrition is needed to benefit the poor. Often, investments in economic growth outpace improvements in health.

If under-nutrition can lead to lower human capital, preventing it could bring about not only health, but also educational and economic benefits. Programs in health and nutrition aimed at women and young children could promote better growth and development, which would improve human capital and by extension increase economic productivity many years later.

The World Bank has positioned nutrition as not only a matter of human rights, but also as an economic investment and an engine for economic growth. Investments in health and nutrition should be seen as a long-term human investment.

Community Management of Acute Malnutrition (CMAM)

CMAM is a methodology for treating acute malnutrition in young children using a case-finding and triage approach. Using the CMAM method, malnourished children receive treatment suited to their nutritional and medical needs. Most malnourished children can be rehabilitated at home with only a small number needing to travel for in-patient care. CMAM is one of World Vision’s core project models in nutrition.

The Community-Based Management of Acute Malnutrition (CMAM) approach enables community volunteers to identify and initiate treatment for children with acute malnutrition before they become seriously ill. Caregivers provide treatment for the majority of children with severe acute malnutrition in the home using Ready-to-Use-Therapeutic Foods (RUTF) and routine medical care. When necessary, severely malnourished children who have medical complications or lack an appetite are referred to in-patient facilities for more intensive treatment.

CMAM programmes also work to integrate treatment with a variety of other longer-term interventions. These are designed to reduce the incidence of malnutrition and improve public health and food security in a sustainable manner.

The CMAM model was developed by Valid International and has been endorsed by WHO and UNICEF. CMAM was originally designed for the emergency context, as an alternative to the traditional model of rehabilitating all severely malnourished children through in-patient care at Therapeutic Feeding Centres. However it is increasingly being implemented in the context of long-term development programming, with several Ministries of Health including components of CMAM in their routine services.

CMAM has been implemented around the world by many governments and NGOs. World Vision’s first CMAM project started in Niger in 2006. Since then, World Vision's CMAM programming has expanded to 15 countries.

CMAM should be implemented in any area where at least 10% of children under 5 are moderately malnourished (low weight for height) and there are aggravating factors present. Aggravating factors include generalized food insecurity, widespread communicable diseases and high crude death rate. The NCOE's Measuring and Promoting Child Growth tool explains how to accurately weigh and measure children.

There are four key components to the CMAM approach:

Ø Community Mobilisation

Build relationships and foster active participation of the community

Identify and mobilise community volunteers for CMAM

Volunteers measure Mid-Upper Arm Circumference (MUAC) of all children under 5 to identify those with acute malnutrition.

Ø Supplementary Feeding Programme (SFP):

Provide take-home food rations and routine basic treatment for families of children with moderate malnutrition but no medical complications

Provide support for other groups with special nutrient requirements, including pregnant and lactating mothers

Ø Outpatient Therapeutic Programme (OTP):

Provide home-based treatment and rehabilitation using RUTF for children with severe acute malnutrition but no medical complications (usually 80-85% of children)

Monitor children’s progress through regular outpatient clinics

Provide food rations to the whole family of each severely malnourished child

Ø Stabilisation Centre/Inpatient Care:

Provide intensive in-patient medical and nutrition care to acutely malnourished children with complications such as anorexia, severe medical issues or severe oedema

Link with OTP to allow early discharge and continued treatment in the community

CMAM targets children under 5 years old and their families, but the whole community is involved. Community leaders, volunteers, health staff and families participate in the screening, care and follow up of children with acute malnutrition. Everybody celebrates as the children enrolled in the CMAM programme gain weight and enjoy better health.

CMAM is a highly effective approach to rehabilitating malnourished children and reducing the number of children who die from acute malnutrition. There a few key secrets to this success:

Community based – children are cared for and treated in their own communities, without having to travel away from home for treatment. The whole family is involved and can also continue their daily activities, rather than one caregiver needing to leave home for an extended time to accompany a malnourished child to a treatment centre. This increases access and participation in the programme, leading to higher coverage and better results.

Active case finding – community volunteers regularly screen and monitor all young children so that cases of malnutrition can be identified early and treated immediately. This leads to high coverage, faster rehabilitation and lower mortality.

Triage approach – most children with severe acute malnutrition can be treated at home which protects them from exposure to infections at the inpatient care centres. Only those with existing serious medical conditions are referred to Stabilisation Centres, and they are discharged back to the community for follow up by the OTP as soon as possible. This reduces mortality and is cost-effective, as inpatient care is highly resource-intense.

Building community capacity – CMAM programmes work with communities to identify, manage and prevent acute malnutrition. This increases community ownership of malnutrition, which in turn increases participation in treatment and prevention activities.

In northeast Nigeria, in the three states of Adamawa, Yobe and Borno that have been affected by the ongoing conflict, one in every five children is severely malnourished. An estimated 940,000 children aged 6 to 59 months across these states are acutely malnourished, 440,000 with Severe Acute Malnutrition and 500,000 with Moderate Acute Malnutrition.

he pilot programmes introduced mechanisms to foster community participation and involvement in CMAM activities. Both programmes engaged with religious leaders, traditional leaders, administration officials, Traditional Birth Attendants (TBAs), Traditional Health Practitioners (THPs) and other key figures of the community (e.g. hairdressers). In Yobe, ACF carried out a Rapid Socio-Cultural Assessment (RSCA) designed to provide a more complete picture of the context in which the programme operates, and the opportunities and challenges presented by it. In order to strengthen case finding, the project identified and trained between 30 – 50 volunteers per SDU. These were identified jointly with community leaders to ensure that they were from communities within the SDU catchment area. By focusing on training a large group of volunteers per health facility, the project pre-empted the high dropout rate that generally accompanies CMAM programmes13.

In Katsina, the programme initially introduced Community Mobilisation mentors to support volunteers (five per SDU) in the sensitisation, case-finding and follow-up activities. The mentoring approach was soon superceded, however, by a desire to reach more cases and the Community Mobilisation mentors became more directly involved in sensitisation activities at community level. From the outset, community volunteers were involved in supporting OTP days at the SDUs. They learned about treatment and this became particularly useful during strikes or at times of conflict, as volunteers supported by Red Cross and National Orientation Agency volunteers (who had received similar training to the community volunteers) were responsible for maintaining activities and avoiding interruptions to the treatment.

The pilot experiences provided ample evidence of the importance of community mobilisation, but also served to highlight the challenge of linking services at SDU level with communities, and the resource implications of this process. The scale-up approach will therefore explore ways of utilising existing resources such as the Nutrition Focal Person and Health Educator at the LGA PHC to support these activities and the work of the Community Volunteers. Linking CMAM with other health activities (such as MNCH weeks, immunisation, malaria programmes) will also be used to increase community awareness about the problem and the services available. RSCAs will be conducted to support community mobilisation activities in programme areas on best message delivery mechanisms; in the new projects areas, RSCA will be used for the first time to collect information for larger (and more heterogeneous) populations. The aim of the partnership is also to create a more meaningful dialogue with beneficiary communities, by creating mechanisms for improved accountability and capable of delivering beneficiaries views about CMAM and its activities to those responsible for CMAM policy and practice.

While nutritional treatment services have become increasingly available in health centres across Nigeria, the need still remains extremely high. Whilst the number of SAM children treated – 44,000 in 2010 alone – are more commonly associated with emergency situations, the only response capable of addressing needs is through horizontal programmes integrated into health systems and communities. The question that the ACF and Save the Children pilot programmes sought to answer is how, in the context of Nigeria, this can be done most effectively and sustainably.

The pilots show that part of the answer lies in thinking about the delivery of CMAM services outside of the traditional NGO model, from rethinking the need for individual stations at OTP level, to admitting children on a weekly (rather than daily) basis. For integration truly to occur, CMAM services need to be tailored to fit health systems at different levels, even if this ultimately leads to significant variations across different locations. There is not one approach that will fit all of Nigeria, or even all the LGAs in a state. Tactical diversity should be encouraged.

Other aspects of CMAM programming need to be strengthened and enforced. CMAM was founded on a commitment to reaching a high proportion of the affected population, and this vision needs to remain at the core of national strategies for their CMAM integration. The number of geographical areas (e.g. states) or facilities within them offering the service is a means to this end, not an end in itself.

Ensuring that integrated CMAM programmes achieve the highest possible coverage is closely linked to the degree of community mobilisation carried out. Scarce resources, overburdened staff, and limited experience have traditionally hampered the ability of health systems to develop community mobilisation strategies to accompany the introduction and implementation of CMAM services. NGOs have a crucial role to play in this regard. Increasing community awareness and participation in activities is a key feature of what local health systems will need to do in order to address needs. In high prevalence areas, like Northern Nigeria, increasing awareness must be accompanied by a simultaneous strengthening of health systems responsible for managing any rise in demand.

The roll-out of CMAM services in many high-prevalence contexts, including Nigeria, has stretched the capacity of government and support agencies to maintain RUTF supplies. The pilot programmes showed the risks of scaling up without proper RUTF supplies, a risk that only increases in magnitude and likelihood with the scale-up of CMAM services on a national scale. Ultimately, the sustainability and quality of CMAM programmes depends on the degree to which governments (at federal, state and local level) are willing and able to ensure adequate procurement and delivery of RUTF. Partners have a vital role in building capacities at all levels on stock management, including accurate forecasting. Having more accurate data on needs help to advocate for state governments and budget allocation.

Delivering this kind of support ultimately requires a redefinition of the role of NGOs, from a traditionally implementing role, to one as an enabler. Technical support proved essential in the implementation of CMAM in Nigeria, at federal, state and local levels. The decision not to include staff in SDUs was certainly vital to the sustainability of the project. The NGO role must become one of capacity strengthening and transfer of skills. Advocacy and the ability to support the development of national policies to create the right environment for CMAM are vital to the success of a scale-up framework.

The pilot programmes introduced mechanisms to foster community participation and involvement in CMAM activities. Both programmes engaged with religious leaders, traditional leaders, administration officials, Traditional Birth Attendants (TBAs), Traditional Health Practitioners (THPs) and other key figures of the community.

In Katsina, the programme initially introduced Community Mobilisation mentors to support volunteers in the sensitisation, case-finding and follow-up activities. The mentoring approach was soon superceded, however, by a desire to reach more cases and the Community Mobilisation mentors became more directly involved in sensitisation activities at community level.

They learned about treatment and this became particularly useful during strikes or at times of conflict, as volunteers supported by Red Cross and National Orientation Agency volunteers (who had received similar training to the community volunteers) were responsible for maintaining activities and avoiding interruptions to the treatment.

The pilot experiences provided ample evidence of the importance of community mobilisation, but also served to highlight the challenge of linking services at SDU level with communities, and the resource implications of this process. The scale-up approach will therefore explore ways of utilising existing resources such as the Nutrition Focal Person and Health Educator at the LGA PHC to support these activities and the work of the Community Volunteers.

Linking CMAM with other health activities (such as MNCH weeks, immunisation, malaria programmes) will also be used to increase community awareness about the problem and the services available. RSCAs will be conducted to support community mobilisation activities in programme areas on best message delivery mechanisms; in the new projects areas, RSCA will be used for the first time to collect information for larger (and more heterogeneous) populations.

The aim of the partnership is also to create a more meaningful dialogue with beneficiary communities, by creating mechanisms for improved accountability and capable of delivering beneficiaries views about CMAM and its activities to those responsible for CMAM policy and practice.

While nutritional treatment services have become increasingly available in health centres across Nigeria, the need still remains extremely high. Whilst the number of SAM children treated – 44,000 in 2010 alone – are more commonly associated with emergency situations, the only response capable of addressing needs is through horizontal programmes integrated into health systems and communities. The question is how, in the context of Nigeria, this can be done most effectively and sustainably.

The pilots show that part of the answer lies in thinking about the delivery of CMAM services outside of the traditional NGO model, from rethinking the need for individual stations at OTP level, to admitting children on a weekly (rather than daily) basis. For integration truly to occur, CMAM services need to be tailored to fit health systems at different levels, even if this ultimately leads to significant variations across different locations. There is not one approach that will fit all of Nigeria, or even all the LGAs in a state. Tactical diversity should be encouraged.

Other aspects of CMAM programming need to be strengthened and enforced. CMAM was founded on a commitment to reaching a high proportion of the affected population, and this vision needs to remain at the core of national strategies for their CMAM integration. The number of geographical areas (e.g. states) or facilities within them offering the service is a means to this end, not an end in itself.

Ensuring that integrated CMAM programmes achieve the highest possible coverage is closely linked to the degree of community mobilisation carried out. Scarce resources, overburdened staff, and limited experience have traditionally hampered the ability of health systems to develop community mobilisation strategies to accompany the introduction and implementation of CMAM services. NGOs have a crucial role to play in this regard. Increasing community awareness and participation in activities is a key feature of what local health systems will need to do in order to address needs. In high prevalence areas, like Northern Nigeria, increasing awareness must be accompanied by a simultaneous strengthening of health systems responsible for managing any rise in demand.

The roll-out of CMAM services in many high-prevalence contexts, including Nigeria, has stretched the capacity of government and support agencies to maintain RUTF supplies. The pilot programmes showed the risks of scaling up without proper RUTF supplies, a risk that only increases in magnitude and likelihood with the scale-up of CMAM services on a national scale. Ultimately, the sustainability and quality of CMAM programmes depends on the degree to which governments (at federal, state and local level) are willing and able to ensure adequate procurement and delivery of RUTF. Partners have a vital role in building capacities at all levels on stock management, including accurate forecasting. Having more accurate data on needs help to advocate for state governments and budget allocation.

Delivering this kind of support ultimately requires a redefinition of the role of NGOs, from a traditionally implementing role, to one as an enabler. Technical support proved essential in the implementation of CMAM in Nigeria, at federal, state and local levels. The decision not to include staff in SDUs was certainly vital to the sustainability of the project. The NGO role must become one of capacity strengthening and transfer of skills. Advocacy and the ability to support the development of national policies to create the right environment for CMAM are vital to the success of a scale-up framework.

Improving nutrition contributes to productivity, economic development, and poverty reduction by improving physical work capacity, cognitive development, school performance, and health by reducing disease and mortality. Poor nutrition perpetuates the cycle of poverty and malnutrition through three main routes - direct losses in productivity from poor physical status and losses caused by disease linked with malnutrition; indirect losses from poor cognitive development and losses in schooling; and losses caused by increased health care costs. The economic costs of malnutrition are very high - several billion dollars a year in terms of lost gross domestic product (GDP). Relying on markets and economic growth alone means it will take more than a generation to solve the problem. But specific investments can accelerate improvement, especially programs for micronutrient fortification and supplementation and community-based growth promotion. The economic returns to investing in such programs are very high.

For many people, the ethical, human rights, and national security arguments for improving nutrition or the tenets of their religious faith are reason enough for action. But there are also strong economic arguments for investing in nutrition:

Ø Improving nutrition increases productivity and economic growth.

Ø Not addressing malnutrition has high costs in terms of higher budget outlays as well as lost GDP.

Ø Returns from programs for improving nutrition far outweigh their costs.

Good nutrition is a basic building block of human capital and, as such, contributes to economic development. In turn, sustainable and equitable growth in developing countries will convert these countries to developed States.

There is much evidence that nutrition and economic development have a two-way relationship. Improved economic development contributes to improved nutrition (albeit at a very modest pace), but more importantly, improved nutrition drives stronger economic growth. Furthermore, as quantified in the Copenhagen Consensus, productivity losses caused by malnutrition are linked to three kinds of losses -those due to:

Ø Direct losses in physical productivity.

Ø Indirect losses from poor cognitive losses and loss in schooling.

Ø Losses in resources from increased health care costs.

Therefore, malnutrition hampers both the physical capacity to perform work as well as earning ability. Malnutrition leads to direct losses in physical productivity Malnutrition leads to death or disease that in turn reduces productivity. For example:

Ø According to the World Health Organization (WHO), underweight is the single largest risk factor contributing to the global burden of disease in the developing world. It leads to nearly 15 percent of the total DALY (disability-adjusted life years) losses in countries with high child mortality. In the developed world, overweight is the seventh highest risk factor and it contributes 7.4 percent of DALY losses.

Ø  Malnutrition is directly or indirectly associated with nearly 60 percent of all child mortality and even mildly underweight children have nearly double the risk of death of their well-nourished counterparts.

Ø Infants with low birth-weight (less than 2.5 kilograms)—reflecting, in part, malnutrition in the womb—are at 2 to 10 times the risk of death compared with normal-birth-weight infants. These same low-birth-weight infants are at a higher risk of non-communicable diseases (NCDs) such as diabetes and cardiovascular disease in adulthood.

Ø Vitamin A deficiency compromises the immune systems of approximately 40 percent of the developing world’s children under age five, leading to the deaths of approximately 1 million young children each year.

Ø Severe iron deficiency anemia causes the deaths in pregnancy and childbirth of more than 60,000 young women a year.

Ø Iodine deficiency in pregnancy causes almost 18 million babies a year to be born mentally impaired; even mildly or moderately iodine-deficient children have IQs that are 10 to 15 points lower than those not deficient.

Ø Maternal foliate deficiency leads to a quarter of a million severe birth defects every year.

The strongest and best documented productivity-nutrition relationships are those related to human capital development in early life. Height has unequivocally been shown to be related to productivity and final height is determined in large part by nutrition from conception to age two. A 1% loss in adult height as a result of childhood stunting is associated with a 1.4 percent loss in productivity. In addition, severe vitamin and mineral deficiencies in the womb and in early childhood can cause blindness, dwarfism, mental retardation, and neural tube defects - all severe handicaps in any society, but particularly limiting in developing countries.

Anemia has a direct and immediate effect on productivity in adults, especially those in physically demanding occupations. Eliminating anemia results in a 5 to 17 percent increase in adult productivity, which adds up to 2 percent of GDP in the worst affected countries.

Malnourished adults are also likely to have higher absenteeism because of illness. In addition to its effect on immune function, poor nutrition also increases susceptibility to chronic diseases in adulthood. Diet-related NCDs include cardiovascular disease, high blood cholesterol, obesity, adultonset diabetes, osteoporosis, high blood pressure, and some cancers.

About 60 percent of all deaths around the world and 47 percent of the burden of disease can be attributed to diet-related chronic diseases. About two-thirds of deaths linked to these diseases occur in the developing world, where the major risk factors are poor diet, physical inactivity, and obesity.

These diseases are increasing at such a rapid rate, even in poor countries, that the phenomenon has been dubbed “the nutrition transition.” Like other types of malnutrition, the strongest for manual labour, it has also been found in the manufacturing sector and among white collar workers.

Malnutrition leads to indirect losses in productivity from poor cognitive development and schooling. Low birth-weight may reduce a person’s IQ by 5 percentage points, stunting may reduce it by 5 to 11 points, and iodine deficiency by as much as 10 to 15 points.

Iron deficiency anemia consistently reduces performance on tests of mental abilities (including IQ) by 8 points or 0.5 to 1.5 standard deviations in children.15 Growth failure before the age of two, anemia during the first two years of life, and iodine deficiency in the womb can have profound and irreversible effects on a child’s ability to learn.

Height and weight affect the likelihood that children will be enrolled at the right time in school. Small and sickly children are often enrolled too late (or never), and they tend to stay in school for less time.18 Malnutrition also affects the ability to learn. Common sense tells us that a hungry child cannot learn properly. Although this is true and short-term hunger does affect cognitive function (particularly attention span), the effects of immediate hunger pale in comparison with the effects on school performance of malnutrition in early life, long before the child ever reaches the classroom.

Children who were malnourished early in life score worse on tests of cognitive function, psychomotor function, and fine motor skills and they have reduced attention spans and lower activity levels. These cognitive skill deficits persist into adulthood and have a direct effect on earnings.

Recent studies have shown that that the positive correlation between nutritional status and both cognitive development and educational attainment also applies to children in normal birth-weight and height ranges. For example, as birth-weight increased by 100 grams among sibling pairs, the mean IQ at age 7 increased 0.5 point for boys and 0.1 point for girls.

Educational attainment at age 26 among cohorts with birth-weights between 3 and 3.5 kilograms was 1.4 times higher compared with those with birth-weights between 2.5 and 3 kilograms. The odds of having attained higher education (beyond compulsory schooling) at age 26 were also 2.6 times higher among the tallest cohort compared with the shortest cohort.

It is also worth noting here that the effect of improved nutrition often extends into the range of what is considered normal - so that improving birth-weights has a positive effect even for children above the 2,500-gram cutoff for low-birth-weight babies, reducing anemia has similar benefits beyond those for people afflicted with “severe or moderate” anemia, and levels of mortality are higher even among mildly underweight children.

Why Invest In Nutrition: Not addressing malnutrition has high costs in lost GDP and higher budget outlays Malnutrition costs low-income countries billions of dollars a year. A recent study, for example, showed that preventing one child from being born with a low birth-weight is worth $580.23, 24 At the country level, it has been estimated that obesity and related NCDs cost China about 2 percent of GDP and in India productivity losses (manual work only) from stunting, iodine deficiency, and iron deficiency together are responsible for a loss of 2.95 percent of GDP.25, 26 Preventing micronutrient deficiencies alone in China will be worth between $2.5 and $5 billion annually in increased GDP, which represents 0.2 to 0.4 percent of annual GDP in China.

Adewole Kehinde is a Journalist and Publisher of Swift Reporters based in Abuja, Nigeria